What if C-sections are better and safer than vaginal birth?

time for change, concept of new, life changing and improvement

In the world of childbirth, it is axiomatic that C-sections are “bad,” high C-section rates are “epidemic” and massive efforts should be directed toward lowering the C-section rate.

But what if C-sections are better and safer than vaginal birth? What if — despite initial risks and costs — they prevent serious, life altering, expensive complications in the future.

An editorial in The American Journal of Obstetrics and Gynecology raises that possibility.

Shouldn’t we be offering all pregnant women a choice of elective C-section?

As Dr. Catherine Bradley explains:

Pelvic organ prolapse (POP) is a benign gynecological condition that has an impact on many women. An estimated 13% (1 in 8) of US adult women will undergo surgery for POP by the age of 80 years, suggesting a great many more women will experience POP symptoms but may seek nonsurgical care or no intervention. Milder POP (prolapse that remains inside the hymen with straining) is usually asymptomatic, but moderate to severe POP is associated with significant and negative effects on women’s daily life activities, including bothersome vaginal bulge or protrusion symptoms, obstructive urinary and defecatory symptoms, sexual dysfunction, and impaired quality of life with effects on mood, sleep, relationships, and social activities.

Although the causes are multifactorial, vaginal birth is the biggest risk factor.

…[I]ncreasing evidence suggests vaginal birth is the most important risk factor for POP, particularly in those presenting at younger ages. Researchers have identified postdelivery levator ani injuries, identified as levator tears and ballooning, as key factors connecting vaginal birth and the development of POP.

A 2011 paper by Handa et al. makes this clear.


Compared with cesarean without labor, spontaneous vaginal birth was associated with a significantly greater odds of stress incontinence (odds ratio [OR] 2.9, 95% confidence interval [CI] 1.5–5.5) and prolapse to or beyond the hymen (OR 5.6, 95% CI 2.2–14.7). Operative vaginal birth significantly increased the odds for all pelvic floor disorders, especially prolapse (OR 7.5, 95% CI 2.7–20.9). These results suggest that 6.8 additional operative births or 8.9 spontaneous vaginal births, relative to cesarean births, would lead to one additional case of prolapse…

In other words, 1 in every 9 women who have a vaginal birth instead of a C-section will go on to develop pelvic organ prolapse. The number is even higher for operative (forceps or vacuum) vaginal birth. One in 7 women who undergo operative vaginal delivery instead of C-section will develop POP.

The consequences are not trivial and a great deal of  vaginal surgery including hysterectomy is done to correct it. That doesn’t count the expense of incontinence pads and the impact on women’s quality of life and sexual function.

We’ve known for a long time that C-sections are safer for babies. It has been nearly 10 years since I first wrote about article Neonatal Morbidity and Mortality After Elective Cesarean Delivery by Signore and Klebanoff appeared in the June 2006 special issue of Clinics in Perinatology focussing on the epidemiology and neonatal effects of C-section.

The authors conducted a decision analysis:

modeling the probability of perinatal death among a hypothetical cohort of 2,000,000 women who had uncomplicated pregnancies at 39 weeks, half of whom underwent ECD and half managed expectantly. After taking multiple chance probabilities into account, the model estimated that although neonatal deaths were increased among women delivered by elective cesarean, overall perinatal mortality was increased among women managed expectantly, because of the ongoing risk for fetal death in pregnancies that continue beyond 39 weeks.

They found that C-sections were dramatically safer for babies:


In other words, if 1 million women underwent C-section at 39 weeks instead of waiting for onset of labor and attempting vaginal delivery, 692 more babies would be saved, 517 cases of intracranial hemorrhage and 377 brachial plexus injuries would be prevented. In exchange, there would be 8476 additional cases of short term respiratory problems, 5536 neonatal lacerations, and 2212 additional cases of postpartum hemorrhage.

Given the short and longterm benefits of C-sections to both babies and mothers, shouldn’t we reconsider our knee-jerk rejection of maternal request C-sections? Shouldn’t we be offering all pregnant women a choice of elective C-section?

Imagine if men experienced lacerations, incontinence and sexual dysfunction in order to have children. Do you think anyone would be wailing about a C-section “epidemic” then? Or would C-sections become as popular as Viagra?